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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />/ l /( `C' <br />c, <br />BUSINESS NAME <br />FACILITY ID # <br />SERVICE REQUEST # <br />FAX # <br />b� �i bJ} }IVI?7j }.� <br />1 <br />r�e7 <br />CITY ,7 ? C C"— STATE L ZIP <br />9)(Q( 401 <br />OWNER/ OPERATOR <br />t <br />CALL (209) 953-1697 <br />if BILLING <br />7�+�k <br />(y jeulck <br />w-0old neecrd 4-o be }rallrra rc,4ed. <br />Q� <br />FOR INSPECTION. <br />CHECK ADDRESS <br />�v�r <br />ACCEPTED BY: <br />EMPLOYEE #: - <br />FACILITY NAME <br />ASSIGNED TO: l/' `� <br />48 HOUR NOTICE <br />EMPLOYEE #: <br />DATE: <br />REQUIRED. <br />�h 2 <br />SITE ADDRESS N <br />1 �( "r(reet <br />//i <br />/,lo <br />J 'r) <br />�( )7 <br />P / E: <br />�It <br />Number <br />Dlre/ction <br />-C Street <br />Name <br />r Zi Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Payment Type <br />Invoice # <br />13(0 O9 1U 5.? <br />1 Received By: <br />Street Number <br />Street Name <br />CITY <br />STATE <br />ZIP <br />PHONE #1 <br />ExT• <br />APN # <br />LAND USE APPLICATION # <br />PHONE #T <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />( ) <br />(C-- <br />CONTRACTOR It SERVICE REQUESTOR <br />REQUESTORr <br />/� ij + C % /J� CHECK If BILLING ADDRESS <br />/ l /( `C' <br />c, <br />BUSINESS NAME <br />PHONE# EXT. <br />HOME or MAILING ADDRESSn i <br />FAX # <br />b� �i bJ} }IVI?7j }.� <br />1 <br />r�e7 <br />CITY ,7 ? C C"— STATE L ZIP <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE:--7/DATE: <br />I -q <br />�7 <br />PROPERTY/ BUSINESS OWNER 0- OPERAT AGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title M <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property to 6� 4(r <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/sit assess, V o <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the s 'If it is <br />provided to me or my representative. spy 4 5 ?, <br />TYPE OF SERVICE REQUESTED: r ` 5e +64 ICS <br />-)e* )qf-VJ G <br />�Nv'N <br />COMMENTS: ie Fu FU� Ivt vdi�thou � Pt'IMt}, <br />(7G4rq5e? JS <br />b� �i bJ} }IVI?7j }.� <br />1 <br />r�e7 <br />bu"k76, <br />J <br />elr,,,+, �ns�ec�or 517e p Gv/ Cta7N sep'c <br />P <br />Ines JJPf unUler GOY16te <br />retml i- <br />tt r n(J tkin� <br />rllo�j fhe,re ►�a►y %e <br />Mtik j')I n-ot be �r,ve>7 <br />Cu»Gerd, <br />7�+�k <br />(y jeulck <br />w-0old neecrd 4-o be }rallrra rc,4ed. <br />�v�r <br />ACCEPTED BY: <br />EMPLOYEE #: - <br />DATE: <br />ASSIGNED TO: l/' `� <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): i <br />�h 2 <br />SERVICE CODE: J <br />J <br />P / E: <br />( a <br />Fee Amount: a <br />Amount Paid 5 <br />, <br />Payment Date <br />Payment Type <br />Invoice # <br />13(0 O9 1U 5.? <br />1 Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />M <br />